PROJECTABSTRACT Bundledpaymentsprovideafixedreimbursementforservicesrelatedtothetreatmentofaconditionor procedurethroughadefined?episode-of-care?.Basedoncostsavingsreportedfromdemonstrationprojects, MedicarerecentlyinitiatedtheComprehensiveCareforJointReplacementModel(CJR),amandatorybundled paymentforhipandkneejointreplacementin67randomlyselectedpopulationcenters.Whileadvocates suggestthatCJRcouldslowtherateofmedicalspendingandimprovethequalityofpatientcare,itsvaluehas ?notbeendefinitivelyshowninrigorouslytestedandvalidatedstudies?.IfCJRhasvalue(decreasedcostswith similarquality,orimprovedqualitywithreasonablecosts),Medicarecouldexpanditnationwide,fundamentally shiftingthefinancialriskofpatientcareontohospitals. Reimbursementpoliciesaretheprimarystructuralelementofhealthcarethatinfluencespatientoutcomes forjointreplacement.However,littleempiricalinformationisavailableaboutthefullimpactofbundledpayment programs.Specifically,wedonotknowhowtheywill(a)affectpatient-reportedpainandfunctioning;?(b) influencethevolumeofproceduresandpost-dischargeservices;?(c)stimulatehospitals?responsetoimprove value;?(d)generalizetoanationalprogram;?and(e)triggerpotentialunintendedconsequences. Weproposetoanswerthesecriticalquestionsforhipandkneejointreplacementbypursuingthreeaims: 1)TodeterminewhetherCJRreducesepisode-of-carecosts,improvespatientsafety,andincreases procedurevolume;?2)Tocomparepatient-reportedpainandfunctionaloutcomes(pre-versuspost-surgery change)basedonhospitalparticipationinabundledpaymentprogram;?and3)Toidentifytheimplementation strategies(i.e.,improvedclinicalpathways,post-operativecarecoordination,implantstandardization,patient riskmanagement)thatmosteffectivelyimprovevalueunderbundledpaymentprograms. WewilluniquelylinkMedicareclaimswithpatientreportedoutcomesfromtheAHRQ-fundedFunctionand OutcomeResearchforComparativeEffectivenessinTotalJointReplacementregistryandaPatient-Centered OutcomesResearchInstitute(PCORI)-fundedlargepragmaticclinicaltrial,ComparativeEffectivenessof PulmonaryEmbolismPreventionafterHipandKneeReplacement.LeveragingtherandomselectionofCJR participantandnon-participanthospitalswillhelpclarifythefullspectrumofpolicyeffectsduetotheprogram. WewillalsobuildonthesurveyexpertisewithinDartmouth?sAHRQ-sponsoredCenterofExcellenceinhigh performinghealthcaresystemstoidentifythemosteffectiveimplementationstrategiesadoptedbyhospitalsto improvevalueunderbundledpayments. Thefindingsfromthisproposedevaluationwillbeofcriticalinteresttopatients,policymakers,publicand privatepayers,andhospitalsconcernedwithimprovinghealthcareefficiencywithoutjeopardizingquality.